A Decision Analysis of Amputation Versus Reconstruction for Severe Open Tibial Fracture from the Physician and Patient Perspectives

Abstract

Although reconstruction is often the primary choice of surgeons following an open tibial fracture, there is no evidence to support the long-term effectiveness of flap reconstruction over below-knee amputation. The aim of this study is to perform a decision analysis to evaluate treatment preferences for type IIIB and IIIC tibial fractures. Reconstructive microsurgeons, physical medicine physicians and patients with lower extremity trauma completed a web-based standard gamble utility survey to generate quality-adjusted life years (QALYs). Physicians assigned quite high utility values, and there was a slight preference for reconstruction over amputation, with a gain of only 0.55 QALY. Patients assigned significantly lower utility values and also favored reconstruction over amputation, but with a larger gain of 5.54 QALYs. The disparate utilities assigned by physicians and patients highlight the necessity of realistic discussion of outcomes, regardless of management methods.

A Cost-Utility Analysis of Amputation versus Salvage for Gustilo Type IIIB and IIIC Open Tibial Fractures

“…These rates were varied in order to find a point at which the utility of amputation is greater than that of reconstruction. However, even under the most extreme conditions – when the complication rate of reconstruction is assumed to be 100% and the complication rate of amputation is expected to be 0% – reconstruction continues to yield higher utility than amputation11.…”

“…To calculate the cost-utility ratios for salvage and amputation following IIIB and IIIC tibial fractures, we combined the authors' previous work on utility, based on a survey of reconstructive microsurgeons and physical medicine and rehabilitation (PM&R) physicians,11 with reworked cost data from the Lower Extremity Assessment Project (LEAP) study10.…”

“…In 2008, we conducted a survey of randomly selected physicians from the American Society for Reconstructive Microsurgery (ASRM) and Physical Medicine and Rehabilitation (PM&R) physicians from the authors' home institution11. In this study, a web-based survey was deployed based on our prior experiences with utility surveys27, 28, using the standard gamble method.…”

“…When dealing with complex operations of uncertain effectiveness, cost-utility analyses can help provide the scientific evidence upon which these decisions can be based. Although costs10 and utilities11 have been measured, a detailed cost-utility analysis with robust sensitivity analysis, which is needed to consider the wide-range of assumptions in clinical decision-making, has not been conducted. This study presents a cost-utility analysis for management of severe open tibial fractures, and will serve to guide surgeons and patients in deciding between the two competing management options.…”

Cross-cultural variation in preference for replantation or revision amputation: Societal and surgeon views

“…In another study, Chung et al reported on amputation versus reconstruction after open tibial fractures, and found that both patients and physicians prefer reconstruction over amputation. However, patients estimated a lower quality of life after amputation than physicians 28 . In this case, although both providers and patients valued the same outcome, physicians appeared to be overestimating the quality of life associated with it.…”